Buy-out Bond Protected Funds Application Form

Transcription

1 Buy-out Bond Protected Funds Application Form te: Please complete in BLOCK CAPITALS. te: The heading of each section shows who is required to complete the section (the member, his/her spouse or the trustees). A Plan Type (as per the illustration) Intermediary Name Financial Advisor Name Personal Details (Member) Mr Mrs Ms Surname R Forename Intermediary Number Address for Correspondence of Birth Marital Status M S Sep. Div. Wid. Sex M F Address Telephone Number (work) (home) (mobile) Nationality Special Instructions Country of Residence Occupation Please describe fully and if your occupation is Company Director please detail the nature of the business. of Joining Service of Leaving Service/Scheme of Joining Scheme (i) Have you ever effected an approved Retirement Annuity Contract (i.e. Personal Pension/ Self-Employed Pension Policies) in respect of a previous non-pensionable employment or while self-employed? (ii) Are you entitled to benefits from other Retirement Benefit Schemes? (iii) Are you a Proprietary (5) Director? - please see note 1 (iv) Are you a 20 Director? - please see note 2 te 1: A proprietary (5) director means a director/employee who, either alone or together with his or her spouse and minor children is or was, at any time within 3 years of the date of (a) the specified normal retirement date, (b) an earlier retirement date, (c) leaving service, or (d) in the case of a pension or part of a pension payable in accordance with a pension adjustment order, the relevant date in relation to that order, the beneficial owner of shares which, when added to any shares held by the trustees of any settlement to which the director or his or her spouse had transferred assets, carry more than 5 per cent of the voting rights in the company providing the benefits or in a company which controls that company. te 2: Appendix I of the Revenue Pensions Manual defines a 20 director as someone who directly or indirectly at any time in the last three years owned or controlled more than 20 of the voting rights in the employer company, or in the parent company of the employer company. 1 Continued overleaf

2 A Personal Details (Member) (continued) If the answer to any of the questions (i) to (iv) is YES, please give details below (continue on a separate sheet, if required). Please include details of all retained benefits, including immediate and deferred pensions for you and your spouse and dependants, and lump sums and gratuities payable on death, retirement and leaving service. Please also advise if any of these benefits are subject to a Pension Adjustment Order following a judicial separation or divorce. Annual Salary/Earnings at of Leaving Service The following must be completed for 20 Directors or if the Scheme Rules require. If you are an Employee: Additional Fluctuating Earnings if any, for the three years immediately prior to leaving service. If you are a 20 Director : Total Earnings for the three years immediately prior to leaving service. B Personal Details (Spouse) Mr Mrs Ms Forename Surname Maiden Name (if applicable) of Birth Sex M F C Protected Funds Choice (Member) Please specify the Protected fund(s) to which your Buy-out Bond (Protected Funds) is to be linked. Units are bought at the ruling price on a date not later than three working days following receipt of the single premium and the completed application form. Fund Name Single Contribution Protected 70 Protected 80 Protected 90 Other TOTAL 100 D Web Access to Policy Information (Member) You can look up details of your Buy-out Bond (including a daily updated value) online at the Client Centre on Do you wish to register for the Client Centre? E Policy Details (Trustees) Transfer Payment* Employee (ordinary contribution) Employee (AVC contribution) Employer Total * Are any benefits included in this Transfer Payment the subject of a Pension Adjustment Order following a judicial separation or divorce?. If yes, please attach a copy of this Pension Adjustment Order. 2

3 F Details of Scheme (from which the transfer payment originates) (Trustees) Full Name of Scheme (the Scheme) Name of Trustee(s) Position(s) of Trustee(s) Address of Trustee(s) Name of Employer Address of Employer Is the Scheme registered with the Pensions Board? If YES, please provide Pensions Board Reference Number. P B Is the Scheme Exempt Approved under Chapter 1, Part 30 of the Taxes Consolidation Act, 1997? If YES, please provide Revenue Reference Number. S F rmal Retirement Age under the Scheme Scheme Definition of Pensionable Salary Scheme Definition of Final Remuneration G Scheme Restrictions (Trustees) Does the Scheme impose any restrictions on early leaver benefits, other than the normal Revenue Limits? If NO, then ignore the rest of Section G and go straight to Section H. If YES, please complete the following: Does the Scheme contain a general power of augmentation up to Revenue Limits? Does the Scheme allow benefits on leaving service and/or on winding up to be provided by an individual policy of the kind proposed for in the Member s name? Does the Scheme provide for benefits on early retirement/late retirement? Does the Scheme make provision for an open market option when the policy matures? Does the Scheme include an option to surrender Member s pension for spouse s or dependant s Death-In-Retirement pension? Does the Scheme include an option to commute Member s pension for a cash lump sum at retirement? Please specify Maximum Cash Lump Sum OR of Final Remuneration Where this bond is being taken out by a non-member spouse under the terms of a Pension Adjustment Order the Scheme Trustees must advise the maximum lump sum payable to the non-member spouse. Has the member waived his/her entitlement to a tax-free lump sum at retirement? Does the Scheme include an option to commute on serious ill-health? If you have answered NO to any of the above questions, please give details; if there are any other special conditions or restrictions, e.g. restriction on tax-free cash, please indicate below. 3

4 H Benefit Details (Trustees) Member's Pension Member's Pension Minimum Guaranteed Payment Period ne 5 years 10 years Spouse's Pension Spouse's Death-In-Retirement Pension If YES, please specify spouse s Death-In-Retirement Pension and ensure that the spouse s declaration (Section J) is completed. of Member s Pension OR p.a. Spouse s Death-In-Retirement Pension to commence on: Member s Death Expiry of Minimum Guaranteed Payment Period Pension Escalation Escalation on Pensions in payment p.a. compound Special Conditions Please specify any other special conditions relating to member s and/or spouse s pensions (e.g. supplementary pension up to State pension age, minimum guaranteed payment period for spouse s pension, etc.). te: Please sign the box at the bottom of part A on next page. I Declarations (continued on next page) Part A (Member) (i) Data Protection Zurich Life Assurance plc ( Zurich Life ) or its authorised agents, may hold, use, disclose and process any information provided by me ( data ), which shall include information contained in this application (or provided subsequently in discussion or otherwise) and any information arising in relation to my policy and my relationship with them, in order to: process this application, manage and administer my policy; provide data to any of the companies that make up the Zurich Financial Services group (the 'Group') to enable them to do so; and provide the data to my Financial Advisor to enable them to administer my policy; comply with legal and regulatory obligations; overview and analyse my policy regularly for Group reporting; communicate with me (subject to legislation) by post, telephone, or SMS unless instructed not to by me in writing; disclose the data to any (or any proposed) assignee, disposee or successor or any reinsurer; disclose/transfer the data abroad (subject to legislation) for the above purposes to persons approved of by Zurich Life; and check my personal data against international trade/economic or financial sanctions laws or regulations listings. You have a right of access to and the right to rectify data concerning you held by Zurich Life/the Group. Zurich Life may, in future, want to use your data to tell you about its products and services, those of the Group or of a third party that they have arranged for you. If you do not want your data to be used for these purposes, please tick here. You can ask Zurich Life/the Group at any time to stop using your data in this way, by writing free of charge to Customer Services, Zurich Life Assurance plc, Zurich House, Frascati Road, FREEPOST, Blackrock, Co. Dublin. (ii) Consumer Disclosure I confirm that I have received the relevant Customer Guide and that the Customer Guide has been fully completed by my Financial Advisor. Does this policy replace an existing policy(ies), in whole or in part? If YES, and that policy is a Zurich Life policy(ies), please specify policy number(s): Warning: If you propose to take out this policy in complete or partial replacement of an existing policy, please take special care to satisfy yourself that this policy meets your needs. In particular, please make sure that you are aware of the financial consequences of replacing your existing policy. If you are in doubt about this, please contact your insurer or Financial Advisor. Continued overleaf 4

5 te: If you are transferring from a defined benefit scheme, it is likely that the benefits under your Buy-out Bond will be significantly different in form. For example, the benefit on retirement may be guaranteed under your employer scheme while Buy-out Bond benefits depend on investment returns (and are not guaranteed). I Declarations (continued) (iii) Policy Declaration I agree that the information given shall be the basis of the contract of insurance, and I declare that the statements in this application are true and complete (including any statements written down at my dictation). I understand that my rights under the Scheme are being given up in exchange for a contract under which the ultimate benefits depend on the future investment returns on the fund(s) in which the Transfer Payment will be invested and cannot be guaranteed. I hereby authorise Zurich Life to seek information and obtain benefit details from the administrator/trustees (and/or relevant insurance office) of any scheme, arrangement or contract of which I am or have been a member, and I authorise the Department of Social Protection or the Revenue Commissioners to advise Zurich Life of my most recent address on their records, at any future time. I hereby authorise the Trustees to transfer to a Buy-out Bond (Protected Funds) the amount that, in the opinion of the said Trustees, represents the value of my benefits on withdrawal under the Scheme. In consideration of the payment of such Transfer Payment to a Buy-out Bond (Protected Funds), I hereby release the Trustees of the Scheme from all liability to me in respect of benefits under the Scheme with effect from the date of such transfer. If the policy was sold, signed or completed outside Ireland, insert the name of the country where it was sold, signed or completed. Member I confirm that I have read and fully understand all parts of the above declaration (Part A, (i), (ii), and (iii)). Signature of Member Part B - This part should be completed by your Financial Advisor. I hereby declare that in accordance with Regulation 6(1) of the Life Assurance (Provision of Information) Regulations, 2001, the applicant(s) has been provided with the information specified in Schedule 1 to those Regulations (the relevant Zurich Life Customer Guide) and that I have advised the client(s) as to the financial consequences of replacing an existing policy with this policy by cancellation or reduction, and of possible financial loss as a result of such replacement. Financial Advisor Signature of Financial Advisor te: Required only if a spouse s pension is provided by the Scheme. J Spouse's Declaration (Spouse) I understand that my rights under the Scheme are being given up in exchange for a contract under which the ultimate benefits depend on the future investment returns on the fund(s) in which the Transfer Payment will be invested and cannot be guaranteed. I understand that the benefits to be provided are specified in Section H. Spouse Signature of Spouse te: A copy of this complete application form is available on written request within three months of the date of application. A copy of the policy conditions is also available. te: It is essential that the person(s) signing on behalf of the Trustee(s) is (are) empowered to do so. K Trustee's Application and Declaration (Trustees) I declare that the information given in this application is complete and correct and request that a Buy-out Bond (Protected Funds) be issued in the name of the Member in accordance with the details set out above, subject to the privileges and conditions of the standard form of policy issued by Zurich Life Assurance plc (Zurich Life) for a contract of the kind proposed. I confirm that the transfer payment arises from the proceeds of a retirement benefits scheme that is or is to be exempt approved under Chapter I, Part 30 of the Taxes Consolidation Act,1997 and the proposed benefits correspond with benefits that could be provided in respect of the Member and his/her spouse under the Rules of the Scheme. I confirm that the Scheme documentation empowers the trustees to purchase the Buy-out Bond (Protected Funds) for the Member in lieu of the benefits for, or in respect of, the Member and his/her spouse under the Scheme. I understand that Zurich Life will provide only the benefits under the Buy-out Bond (Protected Funds) and will accept no further responsibility in relation to the Member and his/her spouse, including responsibility regarding all aspects for the transfer payment from the Scheme. Trustee Signature of Trustee Trustee Signature of Trustee 5

6 Print Ref: ZURL PP Product Ref: QCA Zurich Life Assurance plc Zurich House, Frascati Road, Blackrock, Co. Dublin, Ireland. Telephone: Fax: Website: Zurich Life Assurance plc is regulated by the Central Bank of Ireland. Intended for distribution within the Republic of Ireland. The information contained herein is based on Zurich Life's understanding of current Revenue practice as at February 2011 and may change in the future.